Decision Date: 09/28/95 Archive Date: 01/17/96
DOCKET NO. 93-16 562 ) DATE
)
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On appeal from the
Department of Veterans Affairs Regional Office in St. Louis,
Missouri
THE ISSUE
Entitlement to service connection for the cause of the
veteranís death.
REPRESENTATION
Appellant represented by: Disabled American Veterans
ATTORNEY FOR THE BOARD
J. Connolly, Associate Counsel
INTRODUCTION
The veteran had active service from September 1945 to
December 1952.
This matter came before the Board of Veterans' Appeals
(Board) on appeal from a June 1991, rating decision of the
St. Louis, Missouri, Regional Office (RO) of the Department
of Veterans Affairs (VA). The notice of disagreement was
received in August 1991. The statement of the case was sent
to the appellant in January 1992. The substantive appeal was
received in March 1992.
CONTENTIONS OF APPELLANT ON APPEAL
The appellant contends that the veteranís service-connected
Wolf Parkinson White Syndrome caused or contributed to the
veteranís death.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
ß 7104 (West 1991), has reviewed and considered all of the
evidence and material of record in the veteran's claims file.
Based on its review of the relevant evidence in this matter,
and for the following reasons and bases, it is the decision
of the Board that service connection for the cause of the
veteran's death is warranted.
FINDINGS OF FACT
1. The cause of the veteran's death on November 8, 1990, as
listed on the death certificate, was coronary artery disease
due to diabetes mellitus, with other no significant conditions
contributing to death.
2. At the time of death, the veteran was service connected
for Wolff Parkinson White Syndrome, rated as 10 percent
disabling, and for an appendectomy scar which was assigned a
non-compensable rating.
3. The veteran's service-connected Wolff Parkinson White
Syndrome which affected a vital organ, rendered the veteran
materially less capable of resisting the effects of the other
diseases primarily causing death, thus contributing to cause
the veteranís death.
CONCLUSION OF LAW
Wolff Parkinson White Syndrome contributed substantially or
materially to cause the veteran's death. 38 U.S.C.A. ßß 1310,
5107(b) (West 1991); 38 C.F.R. ß 3.312(c)(1), (3) (1994).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
The appellant's claim as to this issue is well grounded
within the meaning of 38 U.S.C.A. ß 5107 (West 1991). That
is, the Board finds that she has presented a plausible claim.
The Board is also satisfied that all relevant facts have been
properly developed and that no further assistance to the
appellant is required to comply with the duty to assist
mandated by 38 U.S.C.A. ß 5107 (West 1991).
The cause of the veteran's death on November 8, 1990, as
listed on the death certificate, was coronary artery disease
due to diabetes mellitus, with no significant conditions
contributing to death. The veteran was 62 years of age at the
time of death. At the time of death, the veteran was service
connected for Wolff Parkinson White Syndrome, rated as 10
percent disabling, and for an appendectomy scar which was
assigned a non-compensable rating.
Historically, the veteranís service medical records reveal
that he was initially treated in January 1952 for Wolff
Parkinson White Syndrome with Paroxysmal Auricular
Tachycardia. In October 1952, the veteran appeared before a
clinical board. It was noted that the veteran first
complained of recurrent brief bouts of heart palpitation,
dizziness, and weakness lasting from 3 to 15 minutes in
January 1952. Ten of the attacks occurred within a space of 2
weeks. The veteran felt weak after the attacks, but had no
signs of heart failure or anginal pain. It was reported that
physical examination was essentially normal except for an
elevated blood pressure reading of 138/90. Cardiac
fluoroscopy was normal. In September 1952, he was admitted to
the infirmary with a recurrence of the attacks and was
transferred to the hospital where the clinical board took
place. Current EKG was considered consistent with left heart
strain pattern and Wolff Parkinson White complex. In November
1952, the veteran appeared before a physical evaluation board.
It was determined that the veteran suffered from Wolff
Parkinson White Syndrome, Paroxysmal Tachycardia. He was
recommended for discharge.
Following his discharge in December 1952, the veteran filed a
claim for compensation in November 1957. In conjunction with
his claim, the veteran was afforded a VA examination in May
1958. At that time, the veteran denied a history of diabetes,
high blood pressure, rheumatic fever, syphilis, or thyroid
trouble. He reported that he was diagnosed with Wolff
Parkinson White Syndrome in 1952. Physical examination
revealed that the veteran heartís was not enlarged and no
friction rub or gallop was heard. The rhythm was regular. No
murmur was heard in the upright position or prone position.
The examiner thought that it was inadvisable to offer the
veteran an exercise tolerance test. Pulse rate was 84 per
minute and regular. Three blood pressure readings were all
130/90 and respiration was 17. The diagnosis was Wolff
Parkinson White Syndrome with paroxysmal tachycardia.
Based on the service medical records and the VA examination
reports, the veteran was granted entitlement to service
connection for Wolff Parkinson White Syndrome in a June 1958
rating decision and was assigned a 10 percent rating. He was
rated analogously to tachycardia. In a letter received in
June 1958, the veteran elected to receive his Marine Corps
retirement pay instead of compensation benefits.
There are no medical records of record until 1972. A March
1972 hospitalization report of the Christian Hospital
Northwest revealed that the veteran was admitted to the
emergency room with rapid heart rate and shortness of breath.
The diagnosis was Wolff Parkinson White Syndrome with
supraventricular tachycardia. In November 1974, the veteran
was admitted to the same facilityís emergency room with
complaints of a rapid irregular heart beat. He was found to
have a rapid atrial fibrillation. The veteran was converted
to a regular sinus rhythm with electrocountershock. The
diagnosis was paroxysmal atrial fibrillation converted to
normal sinus rhythm and diabetes mellitus.
The veteranís private medical records further reveal that he
was admitted on several occasions to St. Johnís Mercy Medical
Center. It is significant to note that Bernard T. Swaykus,
M.D., a cardiologist, was consistently the veteranís treating
physician over a period of approximately 15 years. December
1975 hospitalization reports of the St. Johnís Mercy Medical
Center reveal that the veteran was admitted to the emergency
room for complaints of headaches. He was diagnosed as having
essential hypertension. December 1976 hospitalization reports
reveal that the veteran was admitted to the emergency room for
complaints of heart palpitations and shortness of breath. He
was noted to have a history of Wolff Parkinson White Syndrome
and a 2 year history of being hypertensive. The final
diagnoses included Wolff Parkinson White Syndrome with acute
atrial fibrillation; probable atherosclerotic cardiovascular
disease; and essential hypertension. May and June 1978
hospitalization reports reveal that the veteran was admitted
for ventricular tachycardia. It was noted that the veteran
had a long history of Wolff Parkinson White Syndrome with
recurrent bouts of superventricular tachycardias. The veteran
was treated with drugs. The diagnoses included Wolff
Parkinson White Syndrome; superventricular tachycardia;
hypertension by history; and arteriosclerotic heart disease,
angina.
In January 1979, the veteran was admitted to the emergency
room of the St. Johnís Mercy Medical Center with complaints of
chest pain. The final diagnoses included arteriosclerotic
heart disease with acute inferposterior myocardial infarction,
subendocarial, transient sinus bradycardia and
supraventricular tachycardia and recurrent myocardial
ischemia; Wolff Parkinson White Syndrome; history of
hypertension; stenosis of the left infernal carotid artery, 50
percent, nonprogressive; and history of abnormal glucose
tolerance. An April 1979 hospitalization report revealed that
the veteran was treated for severe right calf pain. His
medical history was documented. It was noted that he had a
long cardiac history beginning with Wolff Parkinson White
Syndrome which was diagnosed when he was 24 years old.
Approximately 12 years ago, he had an inferior myocardial
infarction and in January 1979, he had a posterior myocardial
infarction. Because of the Wolff Parkinson White Syndrome, it
was noted that the veteran had multiple episodes of cardiac
arrhythmias including ventricular tachycardias. In January
1979, the veteran had a coronary angiogram which showed
complete obliteration in several regions of the anterior
descending and several lesions in the right coronary. It was
determined that the veteran required a triple bypass. The
diagnosis was severe atherosclerotic heart disease requiring
surgery; the Wolff Parkinson White; and right calf pain of
questionable etiology. The veteran received further treatment
which revealed acute phlebitis of the right leg.
A March 1988 hospitalization report of the St. Johnís Mercy
Medical Center revealed that the veteran underwent an elective
aorta-iliac bypass graft. It was noted that the veteran had
diagnoses of severe aorta-iliofemoral occlusive disease with
claudication of the lower extremities; arteriosclerotic heart
disease with angina, old inferior myocardial infarction and
coronary artery bypass graft in 1979; chronic obstructive
pulmonary disease; diabetes mellitus, maturity onset, diet
controlled; hypertension; and intermittent Wolff Parkinson
White Syndrome with atrial fibrillation. A June/July 1989
hospitalization report of the St. Johnís Mercy Medical Center
revealed that the veteran underwent a right carotid
endarterectomy. It was noted that the veteran had diagnoses
of severe cerebrovascular disease with right carotid stenosis
and occluded left internal carotid artery; hypertension;
noninsulin dependent diabetes mellitus; arteriosclerotic heart
disease; chronic obstructive pulmonary disease; and status
post coronary artery bypass graft.
The veteran was also treated at the Lutheran Medical Center.
An August 1989 hospitalization report of the Lutheran Medical
Center revealed that the veteran was admitted with complaints
of palpitations and presyncopal spell with wide QRS
tachycardia. It was noted that he had a history of Wolff
Parkinson White Syndrome. The final diagnoses were wide QRS
tachycardia; history of Wolff Parkinson White Syndrome;
history of three myocardial infarctions and history of
coronary artery bypass surgery in 1979 with evidence of graft
occlusion in June 1989 and recurrent angina; hypertension;
diabetes mellitus; and chronic obstructive pulmonary disease.
The examiner noted that the wide QRS tachycardia was
undiagnosed, likely to be supraventricular with a history of
Wolff Parkinson White Syndrome in the past, however, it was
noted that it could have also been due to ventricular
tachycardia.
A June/July 1990 hospitalization report of the St. Johnís
Mercy Medical Center revealed that the veteran was diagnosed
and treated for severe congestive heart failure. In July
1990, the veteran was readmitted through the emergency room
for moderately severe congestive heart failure. The final
diagnoses were congestive heart failure; chronic obstructive
pulmonary disease; gout; atherosclerotic heart disease;
history of myocardial infarct; status post coronary artery
bypass graft; diabetes mellitus, noninsulin dependent.
As previously noted the cause of the veteran's death on
November 8, 1990, as listed on the death certificate, was
coronary artery disease due to diabetes mellitus, with no
significant conditions contributing to death. Dr. Swaykus
signed the death certificate as the certifying physician.
In support of the appellantís claim, she submitted a letter
from Dr. Swaykus dated in July 1991. In his letter, Dr.
Swaykus informed the appellant that although the veteranís
arteries were severely diseased and no longer operable prior
to his death, his Wolff Parkinson White Syndrome and the
accompanying arrhythmias more than likely contributed to his
morbidity and possible even his mortality. Dr. Swaykus stated
that the veteranís coronary artery disease at the time of his
death was at the end stage, but noted that the veteran could
very well have died in arrhythmic death related to the Wolff
Parkinson White Syndrome.
In February 1993, this case was referred to a VA cardiologist
for an evaluation regarding whether the veteranís Wolff
Parkinson White Syndrome materially contributed to the
veteranís death. The examiner noted that the veteran had a
history of Wolff Parkinson White Syndrome, coronary artery
disease, peripheral vascular disease, diabetes mellitus,
hypertension, congestive heart failure, and chronic
obstructive pulmonary disease. Following a review of the
veteranís medical records, the examiner noted that the
veteranís severe coronary artery disease with depressed left
ventricular systolic function or his Wolff Parkinson White
Syndrome could well have resulted in his death. The examiner
observed that the death certificate listed coronary artery
disease and diabetes mellitus as the causes of death.
However, he further observed that no information contained in
the records provided the exact circumstances surrounding the
veteranís death. The examiner concluded that in the absence
of specific information regarding the circumstances of the
veteranís death, it was impossible to determine the degree to
which each of the potentially fatal problems, coronary artery
disease and Wolff Parkinson White Syndrome, contributed to
death or the degree to which they interacted with each other
to lead to death. The examiner noted that both of those
cardiovascular problems were separate and due to different
causes, but since they could both potentially lead to the
veteranís death and could have interacted with each other to
lead to death, no determination could be made regarding their
relative contributions to the veteranís death.
A grant of service connection for the cause of the veteran's
death is appropriate when a disability incurred in or
aggravated by service or proximately due to or the result of
service-connected disability caused or contributed
substantially or materially to death. 38 U.S.C.A. ßß 1110,
1131, 1310 (West 1991); 38 C.F.R. ßß 3.303, 3.304, 3.310(a),
3.312 (1994). The service-connected disability will be
considered as the principal (primary) cause of death when
such disability, singly or jointly with some other condition,
was the immediate or underlying cause of death or was
etiologically related thereto. 38 C.F.R. ß 3.312 (b) (1994).
Contributory cause of death is inherently one not related to
the principal cause. In determining whether the service-
connected disability contributed to death, it must be shown
that it contributed substantially or materially; that it
combined to cause death; that it aided or lent assistance to
the production of death. It is not sufficient to show that it
casually shared in producing death, but rather it must be
shown that there was a causal connection. 38 C.F.R. ß
3.312 (c)(1) (1994). Generally, minor service-connected
disabilities, particularly those of a static nature or not
affecting a major organ, would not be held to have
contributed to death primarily due to an unrelated
disability. 38 C.F.R. ß 3.312 (c)(2) (1994). Service-
connected diseases or injuries involving active processes
affecting vital organs should receive careful consideration
as a contributory cause of death, the primary cause being
unrelated, from the viewpoint of whether there were resulting
debilitating effects and general impairment of health,
rendering the veteran materially less capable of resisting
the effects of the other diseases primarily causing death.
Where the service-connected condition affects the vital
organs as distinguished from muscular or skeletal functions
and is evaluated as 100 percent disabling, debilitation may
be assumed. 38 C.F.R. ß 3.312 (c)(3) (1994).
The Board will first consider whether there is a basis for a
grant of service connection for the cause of the veteran's
death on a direct basis. The cause of the veteran's death on
July 4, 1989, as listed on the death certificate, was
coronary artery disease due to diabetes mellitus, with no
significant conditions contributing to death. The service
medical records were negative for coronary artery disease
and/or diabetes mellitus. The medical evidence of record
establishes that both coronary artery disease and diabetes
mellitus were not present in service or for many years
thereafter. Service connection may also be granted for
disability which is proximately due to or the result of a
service-connected disease or injury. 38 C.F.R. ß
3.310(a) (1994). The veteran was service-connected for Wolff
Parkinson White Syndrome and an appendectomy scar at the time
of his death. There is no medical evidence of record
establishing that coronary artery disease and/or diabetes
mellitus were proximately due to or the result of Wolff
Parkinson White Syndrome and/or an appendectomy scar.
Accordingly, the Board concludes that coronary artery disease
and/or diabetes mellitus were not incurred in or aggravated
during active service nor were they proximately due to or the
result of service-connected disability. 38 U.S.C.A. ßß 1110,
1131, 1310 (West 1991); 38 C.F.R. ßß 3.310(a), 3.303, 3.304
(1994).
Although there is no basis for a direct grant of service
connection for the cause of the veteranís death, if the
evidence establishes that the veteran's service-connected
disabilities contributed substantially or materially to the
cause of death, service connection will be granted for the
cause of the veteran's death. 38 U.S.C.A. ß 1310 (West 1991);
38 C.F.R. ß 3.312 (1994).
At the outset, the Board notes that the appellant has not
asserted that the veteranís service-connected appendectomy
scar which was rated as non-compensable for many years
preceding his death played any role in his death. The Board
observes that there is no medical evidence of record which
establishes any relationship whatsoever between the veteranís
death from coronary artery disease due to diabetes and an
appendectomy scar. Thus, the Board concludes that the
veteranís service-connected appendectomy scar did not
contribute substantially or materially to the cause of death.
38 C.F.R. ß 3.312(c)(2) (1994).
Rather, it is the appellantís contention that the veteranís
service-connected Wolff Parkinson White Syndrome caused or
contributed substantially or materially to cause the veteranís
death.
Therefore, the question to be resolved is whether the
veteranís service-connected Wolff Parkinson White Syndrome
caused or contributed substantially or materially to cause the
veteranís death. In this regard, the Board notes that the
veteranís treating cardiologist for many years, Dr. Swaykus,
indicated that the veteranís service-connected Wolff Parkinson
White Syndrome contributed to the veteranís morbidity and
possibly his mortality. The Board notes that the medical
records support that the veteran was treated on an emergency
basis on many occasions for his service-connected Wolff
Parkinson White Syndrome by Dr. Swaykus. The Board finds that
Dr. Swaykus, thus, opined that the veteranís service-connected
Wolff Parkinson White Syndrome contributed to his death. The
February 1993 VA cardiologist opined that, in the absence of
specific information regarding the circumstances of the
veteranís death, it was impossible to determine the degree to
which each of the potentially fatal problems, coronary artery
disease and Wolff Parkinson White Syndrome, contributed to
death or the degree to which they interacted with each other
to lead to death.
A review of the two medical opinions revealed that the VA
examiner could not render a determinative opinion without more
specific information, however, he acknowledged that the
veteranís Wolff Parkinson White Syndrome was a potentially
fatal disorder and may have contributed to death. Dr.
Swaykus, on the other hand, clearly stated that although the
veteranís arteries were severely diseased, his Wolff Parkinson
White Syndrome and the accompanying arrhythmias more than
likely contributed or hastened his death. The Board finds
that the opinion of Dr. Swaykus to be probative evidence as he
is a cardiologist and was the veteranís treating physician for
many years prior to his death and was the certifying physician
on the death certificate. The Board finds that the VA
examinerís opinion was not determinative in that it did not
clearly support nor refute the finding that the veteranís
Wolff Parkinson White Syndrome caused and/or contributed to
death.
The Board has reviewed all of the evidence of record
including the two medical opinions and a history of numerous
hospitalization for cardiovascular problems. In light of Dr.
Swaykusís opinion and the medical evidence of record, the
Board finds that the veteranís service-connected Wolff
Parkinson White Syndrome, which affected a vital organ,
rendered the veteran materially less capable of resisting the
effects of the other diseases primarily causing death.
Accordingly, based on the foregoing, the Board concludes that
the veteranís service-connected Wolff Parkinson White
Syndrome, which affected a vital organ, contributed
substantially or materially to cause the veteran's death.
38 U.S.C.A. ß 1310, 5107(b) (West 1991); 38 C.F.R.
ß 3.312(c)(1), (3) (1994).
ORDER
The appeal is granted.
G. H. SHUFELT
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, ß 6, 108 Stat. 740, ___
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. ß 7266 (West
1991), a decision of the Board of Veterans' Appeals granting
less than the complete benefit, or benefits, sought on appeal
is appealable to the United States Court of Veterans Appeals
within 120 days from the date of mailing of notice of the
decision, provided that a Notice of Disagreement concerning
an issue which was before the Board was filed with the agency
of original jurisdiction on or after November 18, 1988.
Veterans' Judicial Review Act, Pub. L. No. 100-687, ß 402
(1988). The date which appears on the face of this decision
constitutes the date of mailing and the copy of this decision
which you have received is your notice of the action taken on
your appeal by the Board of Veterans' Appeals.
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